Healthcare Provider Details

I. General information

NPI: 1669428967
Provider Name (Legal Business Name): MICHAEL J BALDECK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SOUTHWAY AVE STE 2A
LEWISTON ID
83501-2703
US

IV. Provider business mailing address

415 6TH STREET ATTN: PHYSICIAN SERVICES
LEWISTON ID
83501-2434
US

V. Phone/Fax

Practice location:
  • Phone: 208-798-4818
  • Fax: 208-798-8711
Mailing address:
  • Phone: 208-750-7462
  • Fax: 208-750-7467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-185
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: